‘My insurer won’t pay for experimental treatment, even though my consultant wanted to use the treatment’


We look at Gregory's complaint about his insurer not agreeing to pay for experimental treatment.

What happened

Gregory had lymphoma and needed surgery. His treating consultant wanted to carry out an experimental treatment, by using a robot. Shortly before the surgery, the insurer said they wouldn’t approve the use of the robot. Gregory went ahead with the surgery and the insurer paid the bill, apart from the additional cost of the robot. The insurer offered £100 compensation to Gregory for not providing an update when they should have done.

We got information from Gregory’s treating consultant about why he thought a robot needed to be used in Gregory’s case. We looked into the journal articles he referred us to and checked the NICE guidelines. We also checked what the insurer had said to Gregory about the likelihood of covering the treatment during.

How we helped

We explained to Gregory there was no evidence in the medical journals that showed the robot was effective in treating his condition. It also hadn’t been approved by NICE as safe and effective. So we didn’t think it was unreasonable  for the insurer to decline to cover the cost of the robot and pay the remainder of the bill as it was under the policy limit.

Our decision 

We also explained that we thought the offer of £100 was fair. The insurer had made it clear they were unlikely to fund that aspect of the treatment as soon as Gregory mentioned it, and confirmed it wouldn’t be covered before the surgery took place. So we told Gregory we thought his insurer had suggested a fair settlement of the claim